Time to relook at infection control practices for hospital linen

Shashi Balain, MD and CEO at Shubhram Hospital Solutions Private Limited, shares his insights into hospital linen and laundry management

The breakout of COVID 19 pandemic has brought in focus the often ignored and ill-understood role that hospital linen plays in prevention of hospital acquired infections. The first question that every healthcare worker needs to ask and understand is the rationale behind the use of PPEs, specially designed uniforms for healthcare workers, the use of patient dresses, hospital specific bed-linen and specialised linen for use in OTs and Isolation wards. All expenses made by the hospital on hospital linen is definitely not for branding; the sole purpose is to ensure an effective infection control mechanism. The safety of its employees by ensuring they don’t carry home any microbial load from the hospital back to their homes and that patients do not acquire any new infection from the hospital is the paramount responsibility of all hospitals. Effective hospital linen and laundry management practices and the fidelity with which they are implemented play a crucial role in ensuring that the hospital is able to achieve this crucial objective.

The genesis of Shubhram lies in “infection control” through its program of “Shubhram Clean Chain”. The fundamentals of Shubhram Clean Chain are rather simple; but with high degree of process control, and thus higher implementation fidelity, it becomes extremely powerful and effective.

Shubhram maintains a ‘Clean Chain’: Robust systems and processes that ensure a functional and physical separation of ‘clean’ and ‘dirty’ areas throughout the process of collection, washing, and delivery. The Shubhram Clean Chain concept assumes even more significance in times of a Pandemic like COVID 19 as it brings back to focus how important it is to have more detailed protocols and regulations on how hospital linen needs to be handled from collection of soiled linen, to washing, to finishing, packing, and delivering it back to the hospital. Though most hospitals follow a very detailed protocol for sterilisation, the understanding of disinfection through laundry is still rather limited. 

Protocol versus non-protocol based in-house laundry services: A Comparison of major input parameters

Consider the contrast between protocol based versus non-protocol-based hospital linen management. It’s a bomb waiting to explode and we need to ask ourselves three questions: 

1. Are we aware of and ready for the risks? Awareness issues.

2. Do we want to take the risk? We are aware but costs make one take the risks.

3. Is it worth it? A priority issue of where the money needs to be spent.

• Infection control is the holy grail of all hospital protocols. The major focus of all hospital audits such as JCI and NABH is to ensure that all hospital operations have in-built infection control mechanisms so that hospital acquired infections can be prevented.
• Hospitals in India have come a long way in implementing SOPs that help in controlling hospital acquired infections. However, the focus has largely been on operation theatres and general cleanliness. Sources of infection such as linen and laundry have escaped the attention as accreditation bodies such as NABH are yet to have norms like as in EU for such operations. 
• Operation theatres and everything associated with OT such as linen used in procedures have been a major focus of such measures and there are definite protocols in place to ensure” Sterile Linen” in OT. Thus, functioning of CSSDs receive major emphasis and all procedures and documentation is in place to ensure the desired outcome i.e. infection free linen.
• In Europe, both Laundry and CSSD receive equal emphasis as linen used after surgeries or linen outside of OT that has not been completely free of infection are a major source of secondary infections in hospitals.
•  Infection control protocols for washing and process monitoring are as stringent as for CSSD and are governed by norms called Risk Analysis Bio Contamination.

The out-break of COVID 19 has brought back the need of having infection free laundry process as the need of the hour as it is not possible to sterilise all linen and uniforms that are used for the patients, doctors, nurses and other support staff working for Isolation wards. Shubhram, in consultation with its partner Servizi Italia and chemical partner Diversey, issued detailed guidelines on handling wash process of linen used in COVID 19 Isolation wards. 

Shubhram COVID-19 Linen Collection, Handling and Disinfection Protocol

The below guidelines are based on triangulation of information from various reliable and evidence-based sources as follows:

• Experience of dealing with Covid 19 infected linen in Italy by our Italian partners (Servizi Italia) during the current Covid 19 health crisis in Italy
• Advice from the Global Team of our chemical partners Diversey based on their well-researched and evidence-based efficacy of their chemicals against Covid 19
• Shubhram own in-house research based on publications coming from China that has been at the fore-front of dealing with Covid 19 

Though the research on Covid 19 is not peer-reviewed given how recent the problem is, the programs being followed have a very sound research base and are proven to be effective in dealing with the current issue at our other plants in Italy.

This protocol deals with the following three aspects:

1. The wash program being followed by Shubhram especially keeping in mind Covid 19 infected linen
2.  The collection, disinfection at site and bagging of Covid 19 infected linen by the hospital before being handed over to Shubhram staff
3. Handling and transportation of Covid 19 infected linen by Shubhram Staff to the Plant

Shubhram wash programs for Covid 19 infected linen

Shubhram is following robust RABC (Risk Analysis and Bio-Contamination Control) guidelines being followed pan-Europe for overall-all infection control practices at the Shubhram plant to ensure that all linen is totally free from any sort of infection once it is finally processed.

Specifically, for Covid 19 infected or potentially infected linen we have gone for even higher level of infection control programs guided by our Italian partners, Diversey and WHO Guidelines. The program being currently followed for washing at Shubhram is as follows:

1. Thermal disinfection: Shubhram has decided to go for very stringent thermal disinfection processes recommended by Robert Koch-Institutes in Germany (RKI) and go for the higher thermal disinfection. As per RKI’s recommendation, we are now doing the main wash cycle for 10 minutes at 90 degree Celsius. At this temperature and wash duration, the program ensures complete thermal disinfection. The thermal disinfection formula recommended is as follows:
   t(time in minutes) X [T(temperature) – 55° C] >= 250
   
   Shubhram wash programs go way beyond this minimum requirement to ensure complete thermal disinfection.
2. Drain of water: we have programmed the machines to ensure that there is no drain before the main wash.
3.  Chemical disinfection: we are using Clax Build Lite 5 ml/kg) and Clax Sonril Ultra (1.5 mil/kg) in our main wash other than various other chemicals as our main chemical disinfection process.
4. Dedicated machine for washing Covid 19 Linen: We have dedicated one machine for washing Covid 19 linen arriving from hospital isolation wards so that these are not mixed up with any other hospital linen.

In addition to this, the hospital linen wash protocols being followed by Shubhram go way beyond just washing. The Plant is custom designed to be a barrier laundry plant to serve hospitals.  It has complete segregation of clean and dirty area to an extent that even air flow is designed to move from Clean to the Washing side with louvers to ensure a single way air-flow. We maintain a positive air pressure on the clean side and all exhaust systems are on the washing side that actively pull air from the clean to the washing side.

All the machines for hospital washing are barrier machines and 100% automated though a series of conveyer belts to ensure minimal human touch. The design of the plant, use of Continuous Batch Washers that have the ability to wash more than 3.5 tons per hour of linen, we can assure you that with Shubhram your linen-management service is in safe hands and will ensure 24X7 service support to your team during these trying times.

The collection, disinfection at site and bagging of Covid 19 infected linen by the hospital before being handed over to Shubhram staff

Under normal circumstances, Shubhram takes infected linen from hospitals in Yellow Bags that go through Shubhram’s specialised infected linen wash program. However, we are changing our guidelines for India on this process and will insist on hospital following the process of advised by Diversey. The summary of the recommendation is as follows:

Collection and Handling of Infected /Contaminated Linen

1. Worker must wear gloves, gown, respiratory masks, eye protection while directly handling infected soiled linen and laundry (e.g., bedding, towels, personal clothing) as per Standard and Contact Precautions.
2. Handle contaminated textiles and fabrics with minimum agitation to avoid contamination of air, surfaces and persons by aerosolize infectious particles.
3. Bag the contaminated textiles and fabrics at the point of use
   · Do not sort or pre-rinse contaminated textiles or fabrics in patient-care areas
   · Use leak-resistant containment for textiles and fabrics contaminated with blood or body substances
   · Identify bags or containers for contaminated textiles with labels, colour coding, or other alternative means of communication as appropriate
4. Ensure that laundry bags are closed before transporting.
5. Wear appropriate PPE’s for transporting linen bag to pre-treatment area.
6. Frequently perform recommended hand hygiene after removing gloves.
7. Use the designated area identified for pre-treatment before transporting linen onto the vehicle for laundry process.

On site Pre-Treatment of infected linen:

Option – 1 (As per guideline of MOhW)

Sodium hypochlorite solutions – As per Ministry of Health and Family welfare India (MOHW) 525–615 ppm of available chlorine should be used for pre-treatment of infected linen using pre-soak method with contact time 20 minutes followed by fresh water rinse.

Solution Preparation – Take 10 ml of Clax Hypo in 1 litre of fresh potable water (Hardness should be less than 400 ppm) at room temperature (less than 35°C)

Option – 2

Virex II 265 – As per Environmental Protection Agency, USA (EPA claim 70627-24) 660 – 1000 ppm of available QAC can be used for pre-treatment of infected linen using pre-soak method with contact time 30 minutes followed by fresh water rinse.

Solution Preparation – Take 4 – 6 ml of Virex II 256 in 1 litre of fresh potable water (Hardness should be less than 400 ppm) preferred hot water if available.

Depending on availability of recommended chemicals, Shubhram is happy for the hospital to adopt any of the above two options.

Handling and transportation of Covid 19 infected linen by Shubhram Staff to the Plant

Follow standard operating procedures for the containment and disposal of regulated medical waste. Follow standard operating procedures for containing and reprocessing used linen. Wear appropriate PPE when removing soiled linen from the vehicle. 

1. Avoid shaking the linen
2. Clean and disinfect the vehicle in accordance with standard operating procedures. Personnel performing the cleaning should wear a disposable gown and gloves and respiratory protection as needed, during the clean-up process; and all the PPE should be discarded after use.
3. All surfaces that may have come in contact with the materials contaminated during patient care (e.g., Doors, rails, control panels, floors, walls, any other surfaces) should be thoroughly cleaned and disinfected using an EPA-registered hospital disinfectant in accordance with manufacturer’s recommendations.

Shubhram has decided to use a dedicated vehicle to collect all Covid 19 infected Linen collection and not mix it up with our major hospital linen pick-up of other items. As a normal protocol Shubhram dis-infects all its vehicles; but for Covid 19 infected linen transport Shubhram will be dis-infecting the vehicle using specialist programs run for this by Diversey.

Trollies can be a significant source of infection. Shubhram has a trolley autoclave mechanism at the plant where we use steam at high temperatures to completely dis-infect all trollies. All trollies carrying fresh linen and the transport vehicles carrying the trollies are completely free of any infection.

We believe it is high time that the government comes out with detailed protocols and puts in place mechanism to monitor all hospital laundries, in-house or outsourced, so that both the patients and healthcare workers are safe while using hospital provided linen. We can no longer hide behind lack of awareness or lack of protocols and break the clean-chain. We ought to build-upon the awareness created by COVID 19 of the dangers of how rapidly infection can spread if we break the infection control protocols and put in place the best-in-class practices and help our brave healthcare workers stay safe. Infection free linen in our hospitals is everyone’s right and its time we seize this moment of change and awareness and let the healthcare workers take care of the patients rather than be worried about their own PPE.